Effective Jan. 1, 2026, for commercial plans, certain drugs covered under the medical benefit and administered in an outpatient hospital setting – whether in-network or out-of-network – must be dispensed and billed directly by a specialty pharmacy that Priority Health has a reimbursement agreement with.
This is an expansion of our existing billing policy, #092 – Site Neutral Medical Drug, which went into effect for out-of-network providers in Aug. 2025.
Providers who administer impacted drugs will only be reimbursed for the administration.
Why are we making this change?
This policy update allows for review of the requested treatment site for certain specialty drugs that are eligible for coverage under the medical benefit, supporting management of excessive drug costs and making health care more affordable for our members.
Which drugs are impacted?
The Site Neutral Medical Drug billing policy applies when the requested therapy is included on Priority Health’s Medical Drug List (MDL) with the Site of Service (SOS) restriction denoted. Examples include, but are not limited to:
- Keytruda (J9271; Injection, pembrolizumab, 1 mg)
- Solaris (J1299; Injection, eculizumab, 2 mg)
What settings don’t require specialty pharmacy dispensation?
Impacted drugs may not need to be dispensed by a specialty pharmacy if administered (in-network) in:
- A physician’s office
- The member’s home, where the drug is administered by an in-network home infusion provider
- An ambulatory (freestanding), independent infusion suite
Where can you get more information?
See the following for additional details: